Words and illustrations by Roheet Kakaday

The following has been selectively fictionalized to protect the identities of those involved and events that occurred. Names, races, ages, times, conditions, details and more have been modified or excluded. Originally published on The Biopsy.

I just need a refill.” Kevin muttered under his breath, rocking ever so slightly in his chair, his grip fidgeting on the handle of his cane. The crease in his brow, bent from months of constant worry, shifted as the interview went on. One could tell he worked with his hands; the creases in his palms and fingers burrowed deep next to his weathered callouses.

Kevin’s file was littered with a litany of problems that painted a clinical picture — similar to what I see on exams every few weeks — and my mind began imagining him in archetypes. Medical students are trained to become expert pattern recognizers. In the pre-clinical years of medical school, those patterns are layered into the phrases and buzzwords of multiple choice tests. Child with flank pain? Wilm’s tumor. Blood in urine? Nephritic spectrum disease. Sudden dizziness upon standing? Look for Prazosin. The real world, however, is different.

Anxiety was listed among his many diagnoses. That’s probably why he was here; he needed a refill on his medication. If I were his provider, this visit would have been short, but I’m a medical student. There’s a structure I need to follow, details I need to elicit, a report I need to present so that the attending physician may make the best decisions for the patient’s care.

I scribbled on my notepad, Kevin, 35 M. Rx refill…

“And could you tell me which medication you’re taking and why you’re taking it?” I asked.

“I’m taking Xanax for my anxiety. I have anxiety problems, some depression stuff too,” he muttered. His tone was an unique mix of calm, gruff, and subtle, like he had seen or heard things. As I wrote, I could hear the restless shuffle of his feet. He didn’t want to be here. No one wants to be in a doctor’s office.

“May I ask when and why you were diagnosed with anxiety?” His file did not include any such information. Kevin’s demeanor shifted; he gripped his cane tighter, stooped forward, and looked up at me. I took the cue to fold my notebook closed.

“Well…it happened when I was sixteen, man. I was being a stupid teenager, got into the back of a van, didn’t wear my seatbelt. We were stupid kids, you know? But it was past curfew, around 11 PM, and we were driving around town. Got underneath this underpass,” Kevin’s hands swerved along an imaginary path, “and this guy came out of nowhere.”

Kevin smacked his hands together hard. The clap dulled against the bare walls of the fluorescent lit exam room.

“We just started tumbling and rolling down the street. One. Two. Three. And I was in the back, just like a pinball, hitting everything.” He snapped his hand back and forth. “When they found me they told me I didn’t have a single unbroken bone in my body. Concussion. Rib fracture. Tibia fracture. You name it, I had it.”

I was incredulous. Kevin noticed.

“Yeah, man, it was crazy. I’m a mechanic, so I know it’s crazy. It’s crazy that I’m here now. That I have this,” he pointed to his cane, “to help me get around. It’s all God, man. It’s all God.”

“You have someone looking out for you.” I scribbled in my notepad Kevin, 35 M. Rx refill on Xanax. Anxiety. PTSD 2/2 insane car accident. Mechanic. In my head it read, “Kevin is a 35 year old male who presents to clinic today for a prescription refill on Xanax, his anxiolytic medication. He has suffered anxiety for a long time, a byproduct of his PTSD secondary to a horrible car accident in his teens. He is a mechanic.”

“Is anyone living at home with you right now?” I asked.

“Yeah, my son. He gets me through the day.”

“Oh, that’s nice. Where is Mom?”

“Uh, she is out of the picture.” Kevin shifted uncomfortably in his seat again.

“What do you mean?” I focused all my attention on him.

“Well, she just up and left. Booked a one way flight to Arizona and hasn’t called or done the phone video thing or nothing, man. She’s just gone.” Frustration and despair laced his words. “I don’t get it. I got laid off recently, but I’ve been working hard to get a new job. I have one lined up soon. But, you know, it’s hard with the leg and all. All my coworkers know I’m solid, but she just left. And it’s been hard, real hard, especially for my boy. He keeps asking, ‘Where is Mama?’ and I can’t give him an answer.” His brow furrowed deeper and his eyes masked a deep seated pain.

I swallowed the lump in my throat.

“I love her, man, I really do. I married her, you know? But I can’t keep doing this. She can’t just leave and do her own thing without keeping me in the loop. She can’t just remove herself from the situation. So I’m getting a divorce. I have the paperwork ready and it’s going to the court soon.”

Jesus, I thought, why did she just leave? Who just does that to a man; this man, no less? And now he has to force a divorce to keep his sanity? Tears started to sneak into the corners of my eyes. I fought hard to keep the tears back, to keep the composed professional demeanor standing.

I looked down at my note, Kevin, 35 M. Rx refill on Xanax. Anxiety. PTSD 2/2 insane car accident. Mechanic. Lonely.

His note reconfigured in my head, Kakaday, 24 M. PTSD 2/2 heart break. Medical Student. Lonely.

The truth is, I had just lived through a very rough approximation of his situation. And, as I sniffled slightly, it became clear that I hadn’t really moved past it.

I don’t know if Kevin noticed.

I remember when I picked up my phone to call her that evening. I remember everything, painfully.

She was nearly asleep having finished working for hours beyond normal comprehension — typical for us in medical school — and her voice crackled over the phone, groggy.

“Hello?” she managed to mutter. My heart skipped a beat, as it always did when I heard her voice. Perhaps it was the uplifted intonation at the end of her hello; one third greeting, one third question, and one third hopeful, like something incredible would answer that hello.

“This isn’t going to be easy for me. I’ve actually had to write out what I’m about to say because I just can’t think straight right now, ” I said. My emotions were everywhere. I could still remember the feel of her hair, locks that grew coarser the closer they coursed towards the small of her back. The memory of her laugh rang clear in my ears. I remembered the sunflower I had bought her, the one that passed the time in a glass vase on her kitchen counter. Bright and bold, like her, it was a pittance to how I felt about her. She was breathtaking, like the defiant rise of a mesa from its dusty desert lair — just a smidgen beyond belief that she was anything but a mirage.

Our situation was hardly simple, or straightforward, or right. We were both victims of circumstance — distanced contemporaries — but I was taking it especially hard. I wanted to make the sacrifices she couldn’t. With a deep breath, I began and, for five uninterrupted minutes, awkwardly and painfully unburdened the weight I had heaped atop my heart.

Confessions foamed out in shades of burgundy. Regret in tones of grey. Realities in hard blacks and starch whites. Every syllable shredded my composure. My heart is just bleeding everywhere and I need to fold it back into my chest.

I finished breathless and vulnerable—never had I felt so naked. A half minute of static lingered over the phone, punctuated by her breath. My heart was beating in my throat.

And then she artfully tore at me, as she was entitled to do. It hurt, like I knew it would. It was the right decision for us both, so we could be happy in the long term, even if it destroyed everything in the short term. I was reminded of wise words from long ago; if you truly care about them, let them go.

Her last words careened into me, “Good bye. Good night. Good luck.” She exhaled and then there was silence.

Click.

Dropping my phone to the floor, I lay with my face burrowed in a pillow. My mind was swerving; nothing was coherent or organized. Pulling two covers over my body, I shivered myself to sleep that night.

I had become both Kevin and his wife. I had to leave her, to abandon us, unwillingly but necessarily.

The following weeks felt impossible. Conversations lost relevance. Bright sunsets were colorless. School became a terribly difficult struggle. For the first time in my life, my grades plummeted. I lost confidence in who I was, the choices I had made, and why I was where I was. It felt like my identity had fractured.

Kakaday, 24 M. PTSD 2/2 heart break. Medical Student. Lonely. Scared. Confused. Tired. Questioning. Shouting at a dark void. Wondering why. What had he done?

I ended up meeting criteria for minor depression, the consequences of which scared me. So, I reached out to friends, family, and more.

Original from Michael Forsythe (via Paper)

A few months later, I saw Mrs. Almassi for her follow up on a prior blood test. She needed help interpreting the results. Her file noted her as a mother, a nontraditional student at a distant college, and English as her second language.

“Salam aleikum, Mrs. Almassi.” I said, bowing my head slightly and bringing my fingers near my forehead as I entered the room. I figured she would appreciate the classic Middle Eastern greeting.

She touched her chest, “Aleikum salam.”

Mrs. Almassi was a middle aged woman with striking brown eyes that locked away deeper truths. Her garb reflected her traditional Middle Eastern heritage. She had wrapped her hair and the outline of her face in a red and white scarf that ended on her chest. Her plain black floor-length gown was unassuming.

“What brings you in today?” I asked.

“Well, I’m here to see the results of my…the…blood test,” she said with an Arabic-American blend of an accent. “I also want to talk to the doctor about…I have trouble sleeping.”

I scribbled, Almassi, 43 F, Blood test consult. Insomnia.

“Tell me more about this trouble sleeping. When did it start?”

“I think,” she looked up and to the right, “I think it started three months ago after I had cold.”

It seemed odd to me to correlate a cold and insomnia, so I decided to take a different route. “How is life right now? Are you handling college well?”

She hesitated for a moment. “It is hard. It is making me feel not good,” she said.

“When did this ‘not good’ feeling start?”

“Um…I think three months ago.”

Bingo. It would seem her insomnia started three months ago alongside her problems in college, not her incidental cold. Social pressures are hurting her psyche, at least I believed, so I pursued that avenue. Slowly, her story began to emerge — her landlord suddenly had kicked her out despite being a stellar tenant; she was scared for her life because never had anyone admonish her, let alone dump her onto the curb; she was lonely without her fiancé; she felt unsafe and had no idea why. Her ‘not good’ feeling had nothing to do with her cold.

She vented for 25 minutes and then ended with, “I just don’t want to talk about it.” Her unusually long appointment length allowed the attending physician to join us halfway through her session.

We urged her to contact her college’s counseling services, or find someone to discuss her worries at length with because, frankly, we didn’t have the time.

“I just don’t want to talk about it,” she repeated, her face flushing red and her eyes tearing up. She sniffled and fumbled with a tissue paper. “I don’t understand. I am good person. My teachers and my friends say I am good person. I am very strong because I have gone through many things. How does something bad happen to good person?” She was baffled.

I wanted to yell, You need to talk to someone about this! This is clearly affecting you and you’re not taking the time to confront it! Now it’s manifesting as insomnia! And it’ll only get worse. Just, please, talk to someone about it. I wish it could be me, but it can’t, not right now at least.

I remembered my phone call that night from months ago, I just went through what you’re going through — this questioning of why things happen to you. What did you do to deserve this? And, trust me, nothing makes sense. It’s terrible that bad things happen to good people. But that’s just it, it happens. It is unfortunate that we can hurt others just by living our lives, but that’s our reality. You just need to reach out. Find someone. Talk to them. It’ll get better. It did for me.

Indeed, I had become better. I have the luxury of calling some of the most brilliant and empathetic minds in the nation my classmates and friends. My family was a dependable bastion I could rely on anytime of day. Old friends from college and high school wove their way into my life again. When I had reached out months prior, I found more than enough hands to pull me back onto my feet. I hadn’t realized that, at least, not until Ms. Almassi’s struggle with her character echoed my own.

My hand wanted to open for Mrs. Almassi, to brush away her tears, but I knew my place and let the attending physician take over. It was their relationship after all; I was just an observer, a placeholder for the real physician.

Still, I was tumultuous inside.

They say in medicine there are certain things that will always stick—anchoring memories that forever alter clinical approaches.

They say in medicine you will treat innumerable people; some of whom you will save, others who you will assuredly lose.

What they don’t say is how patients end up treating providers simply by virtue of being who they are. Soon enough, those patient-focused pattern recognition skills become reflexive — common connecting threads between patient and provider unravel themselves.

Kevin. Anxiety. Almassi. Insomnia. Roheet. Lonely.

Person. Hurt.

During our “How to be a Doctor 101" course in school, we’re bombarded with more acronyms than we know what to do with; AIDET, AUDIT, PPPPP, OPQRST, CAGE, and more, all of which are meant to help us remember how to create wholesome therapeutic relationships between us and our patients.

Yet, what happens when we providers just don’t have the experience to relate? What happens when there’s no substance to bolster the advice? Do our words and acronyms ring hollow?

Coming of age in medicine is an unusually compressed time of accelerated change.

As medical students, we are told to act as grown ups before many of us have had the chance to grow. We are asked to counsel patients about problems we have never experienced. We are expected to keep giving of ourselves even when there’s no wisdom to proffer. Living out my early twenties in medical school is maturation turned on its head.

There’s a paradox in medicine — we’re considered the healers, but sometimes we need healing. We’re expected to be sage advisors, but sometimes we are the ones who need sage advice.

The truth is we grow right along side patients, especially those young medical students like me. It’s more that we have the capacity to understand, but we haven’t had the chance to understand just yet.

Sometimes we don’t realize that we are hurt or have healed until we’ve seen ourselves, in part or in whole, reflected in our patients. Our profession requires us to give everything outwardly, that it takes a mirror for us see what has happened to us internally.

When we do finally see ourselves, we patch ourselves up, haphazardly, incompletely, in between lectures, morning rounds, and evening sign outs, but we persevere.

Why? Because our patients need us, just as much as we need them.


Thank you to Sarah Kucharski, Dr. Bryan Vartabedian, and Dr. Kirsten Ostherr for their feedback.